Australia’s first evidence-based clinical guidelines for the management of erectile dysfunction (ED) are a timely reminder of the standard of care for this vulnerable patient group amid advertising saturating men’s health platforms online this final football season.
Published in the MJA, the guidelines have been designed by a panel of experts appointed as representatives of the Urological Society of Australia and New Zealand and the Australian chapter of sexual health medicine for the Royal Australasian College of Physicians.
ED affects up to a third of Australian men and is defined as the persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to allow satisfactory sexual activity, occurring for at least 3 months.
The guidelines note that, in Australia, most cases of ED are identified and managed by GPs, with specialist referrals for men who have an incomplete response or require further investigation and treatment.
“This model of shared care … reflects the optimal utilization of care resources and recognizes that general practitioners play an important role in primary care,” the guidelines state.
The main recommendations of the guidelines are:
- a complete medical history and tailored physical examination are essential;
- laboratory tests should include fasting glucose, lipid profile, and total testosterone level;
- Specialized diagnostic tests are recommended in selected cases and the patient should be counseled accordingly;
- lifestyle changes and optimization of existing medical conditions should accompany all ED treatment regimens;
- Oral phosphodiesterase type 5 inhibitor (PDE5i) is an effective first-line medical therapy;
- A penile prosthesis implant may be considered in men who are medically refractory or unable to tolerate the side effects of medical therapy; i
- Pro-erectile regenerative therapy remains largely experimental.
Co-author of the guidelines, Professor Eric Chung, professor of surgery at the University of Queensland, said an important message from the guidelines was the importance of cardiometabolic screening in ED patients to stratify cardiovascular risk and identify occult heart disease.
“ED shares many of the risk factors of cardiovascular disease (CVD), and epidemiological studies have shown that people with CVD are more likely to have severe ED and drug-refractory,” Professor Chung said in InSight+.
“Furthermore, the presence of ED, itself, serves as an important marker for future CVD, and studies have shown that the severity of ED correlates with greater CVD death and overall death.”
Lifestyle interventions were critical, and existing standard ED therapies were often effective and safe after cardiovascular risk stratification, he said.
For those who failed medical therapy (oral and injectable medications), a penile prosthesis implant was a safe, effective and long-lasting treatment option, he said.
“Prosthetic penile implants have been around for nearly 50 years and in Australia, there are three major companies that market these devices,” he said. “Up to one in four men with ED will likely require a penile prosthesis implant as definitive treatment.”
Professor Chung warned that there was “a lot of false advertising and advertising about the treatment of ED”.
In 2015, he published Australia’s first clinical study of low-intensity extracorporeal shock wave therapy in ED, a promising form of regenerative therapy that aspires to promote endothelial revascularization. He has also published the only paper examining shock waves beyond 5 years, as well as an Asia-Pacific guide to shock wave therapy.
Still, Professor Chung said: “There is so much information we still don’t fully know about this type of therapy, including the types of machines, the correct settings for the shock waves and the long-term safety.
“Although regenerative therapy might work in the carefully selected group of men with ED, much data is lacking and it should only be offered in the setting of clinical trials, where there should be no exchange of payment monetary and after careful informed consent”. he said
Professor Chung said patients should also be warned not to use online men’s health platforms that offer ED treatments.
“They often prey on vulnerable men and charge a significant amount of money,” he said. Professor Chung said that, in his opinion, “some of these companies sometimes practice dangerous medicine and do not properly refer patients who need further evaluation, such as cardiovascular checks.”
However, co-author of the guidelines Dr Christopher Love, a urological and prosthetic surgeon in Victoria, said he believed some of the new online men’s health platforms were “not a bad place to start” for men with ED.
Dr. Love is the medical advisor for one such platform and approves the templates used in phone consultations by the site’s doctors, which he said include a basic cardiovascular risk assessment.
“In the beginning, a lot of men just need to talk to someone and understand performance anxiety, and maybe start first-line oral therapy,” she said. “Many patients like the anonymity of not having to talk about sexual dysfunction with the GP they’ve known since they were 4 years old.”
He emphasized the importance of proper cardiovascular risk assessment of patients with ED, saying, “ED should be considered an early warning sign of possible heart disease.”
Dr. Love said he, like the other guideline authors, was concerned about “boutique clinics” offering shockwave therapy and other regenerative treatments, such as platelet-rich plasma injections, at a significant cost to to patients, but with little or no proven benefit.
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